Associations of outdoor fine particulate air pollution and cardiovascular disease in 157 436 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study
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Date
2020Author
Hystad, Perry
Du Plessis, Johan L.
Larkin, Andrew
Rangarajan, Sumathy
AlHabib, Khalid F.
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Show full item recordAbstract
Background Most studies of long-term exposure to outdoor fine particulate matter (PM2·5) and cardiovascular disease
are from high-income countries with relatively low PM2·5 concentrations. It is unclear whether risks are similar in
low-income and middle-income countries (LMICs) and how outdoor PM2·5 contributes to the global burden of
cardiovascular disease. In our analysis of the Prospective Urban and Rural Epidemiology (PURE) study, we aimed to
investigate the association between long-term exposure to PM2·5 concentrations and cardiovascular disease in a large
cohort of adults from 21 high-income, middle-income, and low-income countries.
Methods In this multinational, prospective cohort study, we studied 157 436 adults aged 35–70 years who were
enrolled in the PURE study in countries with ambient PM2·5 estimates, for whom follow-up data were available. Cox
proportional hazard frailty models were used to estimate the associations between long-term mean community
outdoor PM2·5 concentrations and cardiovascular disease events (fatal and non-fatal), cardiovascular disease mortality,
and other non-accidental mortality.
Findings Between Jan 1, 2003, and July 14, 2018, 157436 adults from 747 communities in 21 high-income, middleincome, and low-income countries were enrolled and followed up, of whom 140020 participants resided in LMICs.
During a median follow-up period of 9·3 years (IQR 7·8–10·8; corresponding to 1·4 million person-years), we
documented 9996 non-accidental deaths, of which 3219 were attributed to cardiovascular disease. 9152 (5·8%) of
157436 participants had cardiovascular disease events (fatal and non-fatal incident cardiovascular disease), including
4083 myocardial infarctions and 4139 strokes. Mean 3-year PM2·5 at cohort baseline was 47·5 µg/m³ (range 6–140). In
models adjusted for individual, household, and geographical factors, a 10 µg/m³ increase in PM2·5 was associated with
increased risk for cardiovascular disease events (hazard ratio 1·05 [95% CI 1·03–1·07]), myocardial infarction
(1·03 [1·00–1·05]), stroke (1·07 [1·04–1·10]), and cardiovascular disease mortality (1·03 [1·00–1·05]). Results were
similar for LMICs and communities with high PM2·5 concentrations (>35 µg/m³). The population attributable fraction
for PM2·5 in the PURE cohort was 13·9% (95% CI 8·8–18·6) for cardiovascular disease events, 8·4% (0·0–15·4) for
myocardial infarction, 19·6% (13·0–25·8) for stroke, and 8·3% (0·0–15·2) for cardiovascular disease mortality. We
identified no consistent associations between PM2·5 and risk for non-cardiovascular disease deaths.
Interpretation Long-term outdoor PM2·5 concentrations were associated with increased risks of cardiovascular disease
in adults aged 35–70 years. Air pollution is an important global risk factor for cardiovascular disease and a need exists
to reduce air pollution concentrations, especially in LMICs, where air pollution levels are highest
URI
http://hdl.handle.net/10394/34924https://www.thelancet.com/action/showPdf?pii=S2542-5196%2820%2930103-0
https://doi.org/10.1016/S2542-5196(20)30103-0
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- Faculty of Health Sciences [2385]